Cardiology Flashcards
(328 cards)
1
Q
Axis deviation can be a sign of?
A
Ventricular hypertrophy or bundle branch block
2
Q
How does AV block present?
A
Lengthened PR interval > 200 or a P without a QRS after it.
3
Q
Left bundle branch block findings?
A
QRS > 120. Deep S wave and no R wave in V1. Wide, tall R waves in I, V5, V6.
4
Q
Right bundle branch block findings?
A
RSR’ complex (rabbit ears)
Wide R wave in V1.
Wide S waves in I, V5, V6.
5
Q
Normal axis deviation findings?
A
Positive in lead I and AvF
6
Q
Left axis deviation findings?
A
Positive in lead I. negative in AvF.
7
Q
Right axis deviation findings?
A
Negative in lead I. Positive in AvF.
8
Q
Normal QT interval?
A
Less than 440
9
Q
Long QT syndrome?
A
Underdiagnosed congenital disorder that predisposes patients to ventricular tachyarrhythmias
10
Q
ECG change progression found with ischemia?
A
T-wave inversion, progresses to ST segment changes (depression, elevation) and finally Q waves (>40msec or more than 1/3 of the QRS amplitude)
11
Q
Poor R wave progression can be a sign of?
A
Ischemia (although this is non-specific)
12
Q
Findings for R atrial enlargement?
A
P-wave amplitude in lead II is > 2.5mm. (P pulmonale- peaked P waves)
13
Q
Findings for L atrial abnormality?
A
P-wave width in lead two > 120msec or notched P waves in lead II.
14
Q
LVH findings on ECG
A
Amplitude of S in V1 and R in V5 or V6 is >35mm.
Amplitude of R in aVL + S in V3 > 28 mm in men or 20mm in women.
15
Q
RVH criteria?
A
right axis deviation and an R wave in V1 > 7mm.
16
Q
Kussmaul sign?
A
increase in JVP with inspiration. Often seen in cardiac tamponade and constrictive pericarditis.
17
Q
Name the systolic murmurs.
A
Aortic stenosis Mitral regurgitation Mitral valve prolapse Flow murmur Tricuspid regurg
18
Q
Aortic stenosis radiates to?
A
carotids
19
Q
Mitral regurg character?
A
holosystolic murmur radiate to axilla
20
Q
Mitral valve prolapse character?
A
Midsystolic or late systolic murmur with a preceding click.
21
Q
flow murmur?
A
soft murmur. position dependent (very common and does not imply cardiac disease)
22
Q
Name the diastolic murmurs.
A
Aortic regurg
mitral stenosis
23
Q
Aortic regurg character?
A
Early diastolic decrescendo murmur
24
Q
Mitral stenosis
A
mid/late diastolic, low-pitched murmur with an opening snap
25
When can an S3 gallop be normal?
younger patients and high output states (pregnancy)
26
S4 gallop can be normal when?
younger patients and athletes
27
Increased or bounding peripheral pulses are a sign of?
Compensated aortic regurg
| Patent ductus arteriosus
28
Pulses greater in arms than legs?
Coarctation of aorta
29
Decreased peripheral pulses are sign of?
Peripheral artery disease
| Late-stage heart failure
30
Pulsus paradoxus? Seen when?
Decreased systolic BP with inspiration. Pericardial tamponade, obstructive lung disease, tension pneumo, foreign body in airway
31
Pulsus alternans
alternating weak and strong pulses. cardiac tamponade, impaired left ventricular systolic function. poor prognosis.
32
Pulsus parvus et tardus.
weak and delayed pulses. Aortic Stenosis.
33
Management options for afib
| ABCD
Anticoagulate
B-blockers
C-blockers/cardiovert
Digoxin (refractory cases)
34
Cha2Ds2Vasc2?
score used to estimate stroke risk in patients with afib
35
What Cha2ds2vasc2 score qualifies patient for anticoagulation?
2 or more
36
Name components of Cha2ds2vasc score and the points given to each?
```
CHF- 1 point
HTN - 1 point
Age > 75 - 2 points
Diabetes - 1 point
Stroke/Tia hx- 2 point
Vascular dz - 1 point
Age 65-74 - 1 point
sex female- 1 point
```
37
ECG with slurred upstroke of QRS? Hx of patient passing out with vigorous physical activity?
WPW syndrome. Should advise against physical activity and sign up for electrophysiology study.
38
cause, symptoms, ecg findings, treatment:
Sinus bradycardia
etiology: nml- response to conditioning. sinus node dysfunction. B-blocker or CCB excess.
S: lightheaded, syncope, chest pain, hypotension. can be asymptomatic
ECG: < 60 bpm
Treatment: none if asymp. atropine to increase HR. Pacemaker is definitive treatment in severe cases.
39
cause, symptoms, ecg findings, treatment:
First-degree AV block
E: normal indv. increased vagal tone. b-block, c-block.
S: asymptomatic
ECG: PR interval > 200
Treatment: none
40
cause, symptoms, ecg findings, treatment:
2nd degree AV block (Mobitz type I/Wenckebach)
E: drug effects- digoxin, b-blockers, ccbs) or increase vagal tone, right coronary ischemia or infarction
S: usually asymptomatic
ECG: progressive PR lengthening until dropped beat. PR interval then resets
T: stop drugs. atropine when needed.
41
cause, symptoms, ecg findings, treatment:
2nd degree AV block (Mobitz type II)
E: fibrotic disease of conduction system or from acute, subacute, prior MI
S: syncope- frequent progression to 3rd degree AV block
Ecg: unexpected dropped beats without change in PR interval
T: pacemaker
42
cause, symptoms, ecg findings, treatment:
Third degree AV block
E: no electrical communication between atria and ventricles
S: syncope, dizziness, heart failure, hypotension, cannon a waves
Ecg: no relationship between P and QRS
Treatment: pacemaker
43
cause, symptoms, ecg findings, treatment:
sick sinus syndrome/tachy-brady syndrome
E: intermittent supraventricular tachyarrhythmias and bradyarrhythmias
S: secondary to tachy or brady -> syncope, palpitations, dyspnea, chest pain, TIA, stroke
T: most common indication for pacemaker
44
cause, symptoms, ecg findings, treatment:
sinus tachy
E: normal physiologic response to fear, pain, exercise. secondary to hyperthyroid, volume contraction, infection, PE.
S: palpitations, SOB
EcG: sinus rhythm. Vent rate > 100 bpm.
T: underlying cause
45
cause, symptoms, ecg findings, treatment:
Atrial fibrillation
```
E: (PIRATES)
Pulmonary disease
Ischemia
Rheumatic heart
anemia/atrial myxoma
thyrotoxicosis
ethanol
sepsis
chronic AF- HTN, CHF
```
S: often asymp. SOB, CP, palpitation, irregularly/irreg pulse
ECG: no discernible P waves with variable and irregular QRS response.
T: chronic: Rate control with b-blck, ccbs, digoxin.
anticoag with warfarin for CVasc >2.
unstable or new onset of < 2 days -> cardiovert
new onset > 2 days or unclear, must get TEE to rule out atrial clot
46
cause, symptoms, ecg findings, treatment:
Aflutter
E: circular movement of electrical activity around atrium at 300 bpm
S: usually asymptomatic but can have palpitations, syncope, lightheadedness
Ecg: sawtooth p waves. atrial rate usually 240-320 bpm. vent rate usually 150 bpm.
T: anticoag, rate control, cardiovert guidelines as in afib.
47
cause, symptoms, ecg findings, treatment:
Multifocal atrial tachy
E: multiple atrial pacemakers or reentrant pathways. COPD, hypoxemia
S: may be asymp
Ecg: at least 3 diff p wave morphologies. rate > 100
T: underlying disorder. verapamil or b-block for rate control/suppression of atrial pacemakers (not very effective)
48
cause, symptoms, ecg findings, treatment:
AVNRT
E: reentry circuit in AV node depolarizes the atrium and ventricle nearly simultaneously
S: palpitation, SOB, angina, syncope, lightheaded
ecg: 150-200 bpm. P wave buried in QRS or shortly after
T: cardiovert if hemodynamically unstable. carotid massage, valsalva, adenosine can stop arrhythmia
49
cause, symptoms, ecg findings, treatment:
AVRT
E: ectopic connection between atrium and ventrical that causes reentry circuit (like WPW)
S: palpitation, SOB, angina, syncope, lightheaded
Ecg: retrograde P wave seen after normal QRS. preexcitation delta wave in WPW.
T: cardiovert if hemodynamically unstable. carotid massage, valsalva, adenosine can stop arrhythmia
50
cause, symptoms, ecg findings, treatment:
Paroxysmal atrial tachycardia
E: rapid ectopic pacemaker in atrium (not sinus node)
S: palpitation, SOB, angina, syncope, lightheaded
Ecg: rate > 100. P wave with unusual axis, before each normal QRS
T: adenosine
51
Name the bradyarrhythmias and conduction abnormalities?
1. sinus brady
2. first degree AV block
3. second degree AV block (Mobitz I/Wenckebach)
3. Second degree AV block Mobitz II
4. Third degree AV block
5. Sick Sinus Syndrome (tachy-brady syndrome)
52
List the supraventricular tachyarrhythmias
1. sinus tach
2. AF
3. Aflutter
4. multifocal atrial tachy
5. AVNRT
6. AVRT
7. Paroxysmal atrial tachy
53
List the ventricular tachyarrhythmias
1. PVCs
2. WPW
3. Vtach
4. Vfib
5. Torsades de pointes
54
cause, symptoms, ecg findings, treatment:
PVC
cause: ectopic beats arise from ventricular foci. associated with hypoxia, electrolyte abnormalities, hyperthyroid
S: usually asymp
Ecg: early, wide QRS not preceded by P wave. usually followed by a pause.
T: if symptomatic give B-block. treat underlying cause.
55
cause, symptoms, ecg findings, treatment:
WPW
E: abnormal fast accessory pathway from atria to ventricle
S: palpitations, SOB, dizzy, rarely cardiac death
Ecg: characteristic delta wave with wide QRS and short PR
T: obs for asymp patients
56
cause, symptoms, ecg findings, treatment:
VT
E: ass with CAD, MI, structural heart disease
S: < 30 sec often asymp
>30 sec- palpitation, hypotension, angina, syncope - can progress to vfib and death
Ecg: three or more consec PVCs, wide QRS in regular rapid rhythm. can see AV dissociation
T: cardioversion if unstable. amiodorone, lidocaine, procainamide
57
cause, symptoms, ecg findings, treatment:
VF
E: ass with CAD, structural heart disease, cardiac arrest.
S: syncope, absence of pulse and BP
ecg: totally erratic wide complex tracing
T: immediate electrical defibrillation and ACLS protocol
58
cause, symptoms, ecg findings, treatment:
Torsades
E: associated with long QT syndrome, proarrhythmic response to meds, hypokalemia, congenital deafness, alcoholism
E: sudden cardiac death, palpitations, dizzy, syncope
ecg: polymorphous QRS, VT with rates 150-250
T: mag initially. cardiovert if unstable. correct hypokalemia. stop drugs.
59
What is the ejection fraction in systolic heart failure?
EF < 50%
60
What is the earliest presenting symptom of heart failure?
exertional dyspnea
61
Do diuretics and digoxin have a mortality benefit for CHF patients?
No- symptomatic relief only
62
BNP level of __ may help support CHF?
>500
63
Stages of NYHA CHF I-IV?
I: no limitation of activity; no symptoms with nml activity
II: slight limitation of activity, comfy at rest or with mild exertion
III: marked limitation of activity, comfy ONLY at rest
IV: any physical activity like walking brings on discomfort. symptoms at rest**
64
Acute CHF management
| LMNOP
```
L-lasix (furosemide)
M-morphine
N-nitrates
O-oxygen
P-position upright
(dont forget ACE inhibitor or ARB)
```
65
Loop diuretics ____ calcium. Thiazides ____ calcium.
Loops lose calcium
Thiazides take calcium in
66
Pharm therapy for acute CHF
Loop diuretics, ACE or ARB
Avoid B-block during decompensated CHF but restart once euvolemic
67
Treatment for chronic CHF
Lifestyle- limit dietary sodium and fluid intake
Pharm:
-B-block, ACE/ARB (help prevent remodeling and decrease mortality for NYHA class II-IV. Avoid CCBs (can worsen edema) )
-Loops
-Spironolactone (shown to decrease mortality risk in patients with NYHA class III-IV CHF.
-Daily ASA and statin if underlying cause is prior MI
68
Advanced treatments for chronic CHF
Implantable cardiac defibrillator (ICD): In patients with an EF < 35%
Left ventricular assist device (LVAD) or cardiac transplant may be needed if patients are unresponsive to max medical therapy
69
Is digoxin useful in non-systolic heart failure patients?
NO
70
Loop diuretic side effects?
ototoxicity, hypokalemia, hypocalcemia, dehydration, gout
71
Thiazide diuretic side effects
hypokalemic metabolic alkalosis, hyponatremia, hyperglycemia, hyperlipidemia, hyperuricemia, hypercalcemia
72
K sparing diuretics (Spironolactone)
side effects
Hyperkalemia, gynecomastia, sexual dysfunction
73
carbonic anhydrase inhibitor (acetazolamide) side effects
hyperchloremic metabolic acidosis, neuropathy, NH3 toxicity, sulfa allergy
74
osmotic agents (mannitol) side effects
pulmonary edema, dehydration. Contraindicated in anuria and CHF.
75
3 types of cardiomyopathy?
Dilated, hypertrophic, restrictive
76
What must be present to make diagnosis of dilated cardiomyopathy?
left ventricular dilation and decreased ejection fraction.
77
Causes of dilated cardiomyopathy? What is most common cause?
Most idiopathic. 2dary causes are alcoholic, myocarditis, postpartum status, drugs (doxorubicin, AZT, cocaine), endocrinopathies (thyroid, acromegaly, pheochromocytoma), infection (coxsackievirus, HIV, Chagas, parasites), genetic factors, nutrition (wet beriberi), ischemia, long standing HTN
78
Most common causes of secondary dilated cardiomyopathy?
Ischemia, HTN
79
How to diagnose dilated cardiomyopathy?
Echo is diagnostic
80
Most common cause of sudden death in young healthy athletes in US?
HOCM
81
how is HOCM inherited
autosomal dominant trait in 50% of HOCM patients
82
Causes of hypertrophic cardiomyopathy?
HOCM, HTN, aortic stenosis
83
Key finding for hypertrophic obstructive cardiomyopathy on physical exam?
systolic ejection crescendo-decrescendo murmur that increases with a decrease in preload (valsalva, standing)
84
Treatment of hypertrophic obstructive cardiomyopathy
b-blockers are initial therapy. ccbs secondary. surgery for hocm exists
85
Restrictive cardiomyopathy
decreased elasticity of myocardium leading to impaired diastolic filling
86
causes of restrictive cardiomyopathy
infiltrative disease. amyloidosis, sarcoidosis, hemochromotosis. Or by scarring, fibrosis. 2ndary to radiation
87
Do signs/symptoms or right sided or left sided HF predominant with restrictive cardiomyopathy?
Right sided HF signs. Typically both left and right heart failure are occuring.
EF is normal or decreased
88
How can you further characterize cause of restrictive cardiomyopathy after diagnosing on echo?
C-xray, mri, cardiac cath can help identify sarcoid, amyloid, etc. cardiac biopsy.
89
What will ECG show in patients with amyloidosis?
low voltage ECG
90
Therapy for restrictive cardiomyopathy
limited. palliation only. cautious diuretic use. use of vasodilators to reduce filling pressure.
91
Risk factors for CAD
DM, Family history of early CAD <55 men, <65 women, smoking, dyslipidemia, abdominal obesity, htn, age (males>45, female >55), male gender
92
Major risk factors for CAD
age, male gender, high LDL, low HDL, HTN, family history, smoking
93
Major risk factors for CAD
age, male gender, high LDL, low HDL, HTN, family history, smoking
94
ST segment elevation in abscence of cardiac enzyme elevation in a young woman?
prinzmetal variant angina
| coronary artery vasospasm
95
when is a stress test contraindicated?
patients with abnormal baseline ECGs.
| do not perform stress tests on asymptomatic patients with low pretest probability of disease
96
Common causes of chest pain?
GERD, angina, esophagitis, costochondritis, trauma, pneumonia, anxiety
97
What confirms diagnosis of GERD?
relief of symptoms after PPI use
98
msk/costochondritis pain described as?
tender to palpation and movement
99
Pneumonia/pleuritis pain
worsening with breathing (pleuritic)
100
What 2 drugs have been shown to have mortality benefit in treatment of angina
ASA and B-blockers
101
Treatment for chronic/stable angina?
ASA, b-block, nitroglycerin
102
Is hormone replacement therapy protective against CAD in post-menopausal women?
NO
103
Unstable angina
chest pain that is
1. new onset 2. accelerating
(occurs with less exertion, lasts longer, less responsive to meds)
3. occurs at rest
104
stable angina
exertion only
105
unstable angina signals presence of possible ____
impending infarction based on plaque instability
106
NSTEMI
indicates myocardial necrosis marked by elevations in troponinI and CK-MB isoenzyme without ST seg elevations
107
Enzyme elevations present in unstable angina?
NO
108
How do you risk stratify patients for MI?
TIMI score
109
Treatment of acute angina symptoms
ASA, O2, IV nitro, IV morphine.
consider B-blockers later as hemodynamics allow.
110
What do you receive points for in the TIMI score for unstable angina/NSTEMI
```
History
Age > 65
Three or more CAD risk factors
Known CAD stenosis > 50%
ASA use in past 7 days
```
Presentation
Severe angina (2 or more episodes in 24 hours)
ST deviation >.5mm
+cardiac marker
Score out of 7
111
What should you do if patients have chest pain refractory to meds and a TIMI score > 3?
Give IV heparin, schedule for angio and possible revasc (PCI or CABG)
112
Acute MI treatment
(MOAN)ing from an MI
Morphine
Oxygen
ASA
Nitro
113
What is the best predictor of survival after an ST-elevation MI?
left ventricular EF
114
What will ECG show with an MI?
ST seg elevations or new LBBB. ST seg depressions with dominant R waves in leads V1-V2 can also be reciprical changes indicating posterior wall infarct.
115
Sequence of ECG changes with MI?
peaked T waves, ST seg elevation, Q wave, T wave inversion, ST normalization, T wave normalization over hours/days.
116
What is the most sensitive/specific cardiac enzyme?
troponin I
117
Who may have clinically silent or atypical MIs
women, elderly, diabetics, post-heart transplant patients
118
What enzyme will help measure reinfarction?
CK-MB
119
Ecg findings for inferior MI?
ST seg elevations in II, III, avF. (RCA and PDA).
Obtain right sided ECG to look for ST elevation in right ventricle
120
Anterior MI ecg findings
st elevation in V1-V4 (LAD)
121
Lateral MI ecg findings
ST seg elevation in I, avL, V5-V6
LCX atery
122
Posterior MI
st seg depression in V1-V2 (anterior leads0
Obtain posterior ecg leads V7-V9 to assess for ST segment elevations
123
If patient is in heart failure post MI, what should you give instead of b-block (assuming patient not hypotensive)
ACE-Inh
124
In inferior wall MI, avoid?
nitrates
125
Indications for CABG
Unable to perform PCI (disease diffuse)
Left main coronary artery disease
Triple vessel disease
Depressed ventricle function
126
Interventions for MI?
Emergent angio and PCI should be performed if possible
127
PCI should be performed within _____ minutes?
90
128
contraindications to thrombolysis?
hx hemorrhagic stroke, ischemic stroke, heart failure, cardiogenic shock)
129
If patient presents within ____ hours of chest pain, thrombolysis with tPA, reteplase or streptokinase should be performed instead of PCI.
3 hours
130
Long term treatment post-MI includes?
ASA, AceInhibitors, B-blockers, high dose statins, (LDL < 100), clopidogrel (if PCI was performed)
131
most common complication and most common cause of death following acute MI?
arrhythmias
132
Timeline of common post-MI complications
Day 1: heart failure
Day 2-4: arrhythmia, pericarditis
5-10: left ventricular wall rupture (pericardial tamponade, papillary muscle rupture-mitral regurg)
Weeks/months: ventricular aneurysm (CHF,arrhythmia, mitral regurg, thrombus)
133
Dressler Syndrome
autoimmune process occuring 2-10 weeks post MI
| presenting with fever, pericarditis, pleural effusion, leukocytosis, elevated ESR
134
Dyslipidemia?
Total cholesterol > 200
LDL > 130
TGs > 150
HDL < 40
135
Causes of dyslipidemia?
obesity, alcoholism, DM, hypothyroid, nephrotic syndrome, hepatic disease, cushings, OCP use, high dose diuretics, familial
136
Xanthomas
(eruptive nodules in skin over the tendons)- caused by very high LDL or TG
137
Xanthelasmas
yellow fatty deposits in skin around eyes
138
Lipemia retinalis
creamy appearance of retinal vessels
139
Screening for hyperlipidemia?
fasting lipid screen for patients > 35 or in those > 20 with CAD risk factors.
Repeat every 5 years or sooner if lipid levels are elevated.
140
Diagnosis for hyperlipidemia?
Total cholesterol >200 on two diff occasions.
LDL > 130 or HDL < 40 is diagnostic of dyslipidemia even if total is < 200
141
treatment for hyperlipidemia is based on?
is based on risk stratification using risk calculator
142
For patients with history of CAD, CVA or PAD use what med?
high intensity statin
143
Patients with LDL between 70-189 without diabetes how do you treat?
Choose high, moderate or low intensity statin based on risk factors
144
Patients with LDL between 70-189 with diabetes treat with?
choose high or moderate based on risk factors
145
LDL > 190 treat with?
high intensity statin
146
First intervention for hyperlipidemia for patient with no risk factors for atherosclerotic disease?
12 week trial of diet/exercise
147
List the common lipid lowering agents
Statins, Fibrates, Niacin, Bile acid resins, cholesterol absorption inhibitors
148
mechanism, effect, side effects? Statins
HMG-CoA reductase inhibitors
decrease LDL, decrease Tgs
SE: increase LFT, myositis, warfarin potentiation
149
mechanism, effect, side effects? Gemfibrozil
Fibrate: Lipoprotein lipase stimulator. Decrease TGs, increase HDL**
SE: GI upset, cholelithiasis, myositis, increased LFTs
150
mechanism, effect, side effects? Ezetimibe
Cholesterol absorption inhibitors. Decrease LDL.
SE: diarrhea, abdominal pain. angioedema.
151
mechanism, effect, side effects? Niacin
Increase HDL**, lower LDL
SE: skin flushing (ASA can prevent this), paresthesias, puritis, GI upset, elevated LFTs
152
mechanism, effect, side effects? cholestyramine, colestipol
Bile acid resins, decrease HDL
SE: constipation, GI upset, LFT elevated, myalgias. Can decrease absorption of other drugs from small Intestine.
153
HTN definition/diagnosis?
BP > 140 and or diastolic BP > 90 based on 3 measurements separated in time in patients < 60
154
How do you define HTN in patients >60 without diabetes or CKD?
>150 or diastolic >90
155
Risk factors for primary essential htn
family history htn or heart disease, high sodium diet, smoking, obesity, ethnicity (black >white), advanced age
156
What labs should you order to work up patient for HTN?
urinalysis, BUN/Cr, electrolytes
157
Treatment of HTN
lifestyle mod
| BP goals vary by age and comorbidities
158
Pharm treatment of HTN?
Ace/Arb
B-block
CCB
Diuretic (particularly thiazide)
159
What drugs have been shown to decrease mortality in uncomplicated HTN?
diuretics, CCB, AceI, b-blocker
160
When to initiate treatment/what are treatment goals for >60?
>150 / > 90 initiate treatment
<150 / <90 treatment goals
161
When to initiate treatment/what are treatment goals for <60?
>140 and >90 initiate
<140 and < 90 goal
162
When to initiate treatment/what are treatment goals for > 18 with CKD or diabetes?
>140 / >90 initiate
<140 / <90 goal
163
Woman found with pulseless electrical activity on hospital day 7 after suffering lateral wall STEMI. ACLS initiated. Next step?
Patient has likely suffered ventricular wall rupture with acute cardiac tamponade. emergent pericardiocentesis is next best step
164
Pharm Treatment of HTN in uncomplicated patients?
diuretic, ccb, ace inhibitor
165
Pharm Treatment of HTN in CHF?
diuretic, b-block, ace, arb, aldo antag
166
Pharm Treatment of HTN in DM?
diuretics, b-block, ace, arb, ccb
167
Pharm Treatment of HTN in post-MI?
b-block, ace, arb, aldo antag
168
Pharm Treatment of HTN in CKD?
ace, arb
169
Pharm Treatment of HTN in BPH?
diuretics, a-adrenergic blockers
170
Pharm Treatment of HTN in isolated systolic htn?
diuretic, aceI, ccb
171
Pharm Treatment of HTN in pregnancy?
b-blockers (labetalol), hydralazine
172
Causes of 2ndary htn?
| CHAPS
```
C-cushing syndrome
H-hyperaldosteronism (conn)
A- aortic coarctation
P-pheo
S- stenosis of renal artery
```
173
htn emergencies are diagnosed based on?
extent of end organ damage. NOT BP
174
When to worry about htn crises
BP > 180/120
175
how will patients with htn emergency present?
end organ damage revealed by acute kidney injury, chest pain (ischemia, MI), back pain (dissection), changes in mental status (hypertensive encephalopathy)
176
htn urgency
elevated BP with mild to moderate symptoms (headache, chest pain) without end organ damage
177
htn emergency
elevated BP with signs/symptoms of impeding organ damage
178
Treatment for htn urgency?
oral anti-htn (b-block, clonidine, Ace) with goal of gradual lowering over 24-48 hours
179
treatment for htn emergency?
IV meds (labetalol, nitroprusside, nicardipine) with goal of lowering MAP by no more than 25% over first 2 hours to prevent cerebral hypoperfusion
180
Cause of renal artery stenosis in younger patients?
fibromuscular dysplasia
181
Why dont we give ACE-Inh in patients with bilateral renal artery stenosis?
can accelerate kidney failure by preferential vasodilation of efferent arteriole.
182
Causes of pericarditis?
most common- idiopathic
| viral, TB, SLE, uremia, drugs, radiation, neoplasm, post-mI, Dressler syndrome, aortic dissection, rheumatic fever
183
Presentation of pericarditis?
pleuritic chest pain, dyspnea, cough, fever
184
How does position affect pain in pericarditis?
Pain worsens in supine position and with inspiration. classic patient seen sitting up and bending forward.
185
Physical exam findings for pericarditis?
pericardial friction rub. elevated JVP and pulsus paradoxus (decrease in systolic BP >10 on inspiration)
186
Initial tests in diagnosis of pericarditis?
CXR, ECG, echo to rule out MI and pneumonia
187
ECG changes for pericarditis?
diffuse ST-segment elevation and PR-segment depressions followed by T wave inversions
188
How to treat pericarditis?
underlying cause
steroids for SLE
dialysis for uremia
ASA for post- MI
ASA NSAIDs for viral
189
why avoid steroids within a few days after MI?
predispose to ventricular wall rupture
190
when is pericardiocentesis required?
evidence of cardiac tamponade. effusions without symptoms can be monitored.
191
cardiac tamponade
excess fluid in pericardial sac leading to compromised ventricle filling and decreased cardiac output.
192
risk factors for tamponade
pericarditis, malignancy, SLE, TB, trauma (stab wounds medial to left nipple)
193
What triad can diagnose acute cardiac tamponade?
Beck triad
| JVD, hypotension, distant heart sounds
194
For cardiac tamponade what do echo, cxray and ecg show?
echo: right atrial and right ventricle diastolic collapse
cxr: enlarged, globular, water-bottle heart
ecg: electrical alternans
195
Treatment of cardiac tamponade
aggressive volume expansion with IV fluids
urgent pericardiocentesis
decompensating patient -> go to pericardial window
196
When does a triple AAA require surgical repair?
> 5cm
197
Aortic aneurysm
greater than 50% dilatation of all three layers of aortic wall.
198
Aneurysms are most commonly associated with what vascular pathology?
Atherosclerosis
199
Most aortic aneurysms originate?
abdominal, below renal arteries
200
Are aortic aneurysms typically symptomatic?
NO
201
on physical exam?
pulsatile abdominal mass or abdominal bruits
202
risk factors for aortic aneurysm
htn, high cholesterol, fam hx, smoking, male, age
203
ruptured aneurysm signs/symptoms?
hypotension and severe tearing abdominal pain that radiates to back
204
screening for AA?
all men 65-75 with history of smoking
205
surgical repair for thoracic AAA is indicated for ____ cm?
6 cm or smaller but rapidly enlarging
206
aortic aneurysm is most often linked to ______ where as aortic dissection is most often linked to _____?
aneurysm: atherosclerosis
dissection: HTN
207
What are indications for valve replacement in patients with aortic stenosis?
symptoms of ACS, angina, CHF, syncope
208
most common etiology of mitral valve stenosis
rheumatic fever
209
primary cause of mitral valve prolapse
rheumatic fever or chordea tendineae rupture post MI. also infectious endocarditis.
210
Causes of acute aortic regurg?
infective endocarditis, aortic dissection, chest trauma
211
causes of chronic aortic regurg?
valve malformation, rheumatic fever, connective tissue disease
212
head bob and water hammer pulses are seen with?
aortic regurg
213
treatment for aortic regurg?
vasodilator therapy (dihydropyridines or ACE-In)
214
treatment for mitral valve regurg?
antiarrhythmics if necessary as afib is common with LAE. nitrates and diuretics to decrease preload
215
most common sites for aortic dissection?
above aortic valve and distal to left subclavian artery
216
presentation of aortic dissection?
sudden tearing, ripping pain in chest or back. typically htn. asymmetric pulses and BP measurements. aortic regurg murmur may be heard. neuro deficits possible if aortic arch or spinal arteries involved
217
presentation of ruptured aortic aneurysm
hypotension, severe, tearing abdominal pain radiating to back
218
gold standard for imaging for aortic dissection?
CT angiography
219
Treatment for dissection?
manage BP and heart rate. avoid thrombolytics. begin B-blockade before vasodilators to prevent reflex tachycardia.
220
If dissection involves ascending aorta?
surgical emergency
221
Virchow triad
hemostasis, trauma(endothelial damage), hypercoaguability
222
diagnosis of DVT?
dopplar ultrasound
223
diagnosis of PE?
spiral CT or V/Q scan
224
How can d-dimer be used to eval for PE?
- d-dimer test can be used to rule out possibility of PE in a low risk patient
225
treatment for DVT?
anticoagulate with IV unfrac heparin or subcu low molecular weight heparin followed by PO warfarin for a total of 3-6 months
226
For patients with DVT and contraindications to anticoagulation what should you do?
IVC filters
227
The 6 P's of acute ischemia
```
Pain
Pallor
Paralysis
Pulse deficit
Paresthesias
Poikilothermia
```
228
rest pain usually occurs with an ABI of ?
229
ABI =
Pleg/Parm
230
normal ABI?
1.0-1.2
231
pharm treatment for peripheral vascular disease?
ASA, cilostazol, thromboxane inhibitors
232
immigrant presents with progressive swelling of lower extremities bilaterally with no cardiac abnormalities?
lymphedema. filariasis infection
233
children present with progressive bilateral swelling of extremities
primary (congenital) lymphedema
234
Are diuretics effective for lyphedema?
No
235
patients with lyphedema are at higher risk for?
cellulitis infection. prophylactic antibiotic coverage will be helpful
236
cardiac related syncope is associated with 1 year sudden cardiac death rates of up to?
40%
237
amiodorone
class III antiarrhythmic used for management of ventricular arrhythmias in patients with coronary artery disease and ischemic cardiomyopathy
238
side effects of amiodorone
chronic interstitial pneumonitis, hypo/hyperthyroidism.
GI/hepatic- elevated transaminases, hepatitis. corneal microdeposits. optic neuropathy. blue-gray skin discoloration. peripheral neuropathy. heart block, sinus brady, prolong QT-torsades.
239
Pulmonary toxicity from amiodorone use correlates with total cumulative dose. True or false?
TRUE
240
What tests should be done before initiating amiodorone?
PFT, cxray
241
westermark's sign
sign seen in cxray of patient with PE. collapse of a vessel distal to PE
(peripheral hyperlucency due to oligemia (hypovolemia))
242
hampton's hump sign
peripheral wedge of opacity in lung due to pulmonary infarct likely from PE.
243
Fleischner sign
enlarged pulmonary atery
244
peptic ulcer perforation presents with?
acute abdominal pain with radiation to the back or the shoulder with signs of peritonitis and likely to see free air under diaphragm on cxray
245
Marfans
autosomal dominant due to mutations in extracellular matrix protein fibrillin-1
246
cardiac manifestations of marfans
aortic dissection, aortic regurg, mitral valve prolapse
247
wide fixed splitting of S2
ASD
248
Holt-Oram (heart-hand syndrome)
Upper limb defects (radius, carpal deformities and ASD)
249
All patients with new onset afib should have what hormone checked?
TSH, T4
250
Management of STEMI
1. Oxygen for O2 sat < 90%
2. Nitrates
3. ASA / Clopidogrel
4. Anticoag
5. B-block (not in heart failure)
6. Prompt perfusion with PCI (ideal if less than 90 minutes to balloon)
7. statin
251
Current guidelines recommend PCI for patients with acute STEMI as follows:
- within 12 hours of symptom onset
- within 90 minutes door to balloon at PCI facility
- within 120 minutes from first medical contact at non-PCI facility
252
systemic atheroembolism
| systemic crystal embolism
aortic atherosclerotic plaques can lead to systemic emboli (can be spontaneous but is more common with vascular procedures)
253
Typical symptoms of systemic cholesterol emobilization
acute/subacute renal failure, GI pain, skin manifestations (livedo reticularis
254
What will labs show for systemic atheroembolism?
EOSINOPHILIA, hypocomplementemia
| elevated BUN/Cr with few cells/casts
255
What is the sensitivity of BNP for diagnosing CHF?
HIGH. 90%
256
Most patients with CHF have plasma BNP levels greater than ?
400
257
BNP levels less than ____ have a negative predictive value for CHF
100
258
sensitivity of cardiomegaly on cxray?
low. 60%
259
Clinical signs of CHF (JVD, lower ext edema, lung crackles) have high sensitivity or specificity?
specificity
260
systolic murmur at sternal border that increases with inspiration?
tricuspic regurg
261
Isolated systolic hypertension
systolic BP > 140 with normal diastolic <90
262
ISH is associated with?
severalfold increase in risk of cardiovascular morbidity/mortality
263
Pathophysiology of isolated systolic BP?
increased stiffness, decreased elasticity of aortic and arterial walls in elderly patients
264
tachy-mediated cardiomyopathy
variety of tachyarrhythmias can cause structural changes in the heart if they are prolonged. including LV dilation and myocardial dysfunction
265
how do you treat tachy-mediated cardiomyopathy?
aggressive rate control and restoration of normal sinus rhythm
266
An important side effect to keep in mind for dihydropyridine Ca channel antagonists like amlodipine?
Peripheral edema! due to dilation of peripheral blood vessels
267
cardiac non caseating granulomas?
sarcoidosis
268
most common complication of cardiac sarcoidosis?
conduction defects. complete AV block is most common.
269
Who is at increased risk of developing peri-infarction pericarditis?
patients with delayed coronary reperfusion following ST-elevation MI
270
Treatment of peri-infarct pericarditis?
supportive
271
Inability to palpate the PMI is consistent with?
Large pericardial effusion
272
Pulsus bisferiens (biphasic pulse)
2 strong systolic peaks of the aortic pulse from the left ventricular ejection separated by midsystolic dip. (patients with siginificant AORTIC REGURG)
273
enlarged water bottle shaped cardiac silhouette
pericardial effusion
274
Presentation of fibromuscular dysplasia
90% women (adults)
1. internal carotid artery stenosis
- recurrent HA
- pulsatile tinnitus
- TIA
- stroke
2. Renal artery stenosis
- 2ndary htn
- flank pain
275
What may you find on PE in women with fibromuscular dysplasia?
- subauricular systolic bruit
| - abdominal bruit
276
how to diagnose fibromuscular dysplasia?
duplex US, CTA, MRA
| catheter based arteriography
277
treatment for fibromuscular dysplasia?
ACE or ARB - 1st line
PTA (percutaneous transluminal angioplasty)
Surgery (if PTA doesn't work)
278
fibromuscular dysplasia may lead to?
arterial stenosis, aneurysm, dissection
279
aortic coarctation presents with?
upper extremity htn. HA. LE claudication.
280
SLE is a known risk factor for?
accelerated atherosclerosis and premature coronary heart disease
281
______ is recommended as an initial test for diagnosis and risk stratification of most patients with suspected stable angina
Exercise ECG
282
_______ is performed in patients with high risk findings on cardiac stress testing
coronary angiography
283
Secondary amyloidosis can be caused by the following conditions:
```
Inflammatory arthritis
Chronic infection
IBD
Malignancy
Vasculitis
```
284
Amyloidosis diagnosis
abdominal fat pad aspiration
285
amyloidosis presentation
- asymptomatic proteinuria or nephrotic syndrome
- restrictive cardiomyopathy
- hepatomegaly
- peripheral neuropathy
- visible organ enlargement (macroglossia)
- bleeding diathesis
- waxy thickening, easy bruising of skin
- orthostatic hypotension
286
Cardiac amyloidosis should be suspected in patients with ____ findings on ECG? echo?
low voltage ECG
Echo shows increased ventricular wall thickness with normal LV cavity
287
Be particularly suspicious of amyloidosis in patients with
CHF, diastolic dysfunction and without HTN
288
Alcoholic cardiomyopathy is dilated or concentric?
dilated
289
patients with hemochromatosis can develop dilated or concentric cardiomyopathy?
dilated
290
Systemic symptoms of hemochromotosis
cardiomyopathy (dilated)
liver disease hepatomegaly, LFT elevated, cirrhosis
Arthropathy
Skin pigmentation
DM
hypogonadism
decreased libido and erectile dysfunction in men
291
systemic symptoms of sarcoidosis
```
heart failure (systolic or diastolic)
hilar adenopathy
reticular opacities
erythema nodosum
uveitis
```
292
Common causes of cor pulmonale
COPD
ILD
Pulm vasc disease (thromboembolic)
Obstructive sleep apnea
293
What might you find on ECG for a patient with cor pulmonale
- partial or complete RBBB
- right axis deviation
- RVH
- Right atrial enlargement
294
Echo findings in cor pulmonale?
- Pulm HTN
- dilated right ventricle
- tricuspid regurg
295
Gold standard for diagnosis of cor pulmonale?
Right heart catheterization - showing right ventricular dysfunction, pulm htn, no left heart diease
296
cor pulmonale
impaired function of right ventricle caused by pulmonary htn (right ventricular heart dysfunction due to left heart disease or congenital disease is not cor pulmonale)
297
holosytolic murmur at left sternal border that changes with inspiration?
tricuspid regurg
298
Right heart cath in patient with cor pulmonale will show?
elevated pulmonary artery pressure >25
299
PCWP is an estimation of?
left ventricular end diastolic pressure
300
PCWP is elevated in patients with? Will have what physical exam finding typically>
LV systolic or end diastolic dysfunction.
Pulmonary edema
301
In addition to standard MI therapy, patients with inferior wall MIs are also typically treated with? Why?
IV fluid boluses due to decreased preload and resulting hypotension with RV dysfunction
302
S1Q3T3 pattern?
Pulmonary embolism
303
Ascending aortic aneurysms are most often due to?
cystic medial necrosis that occurs with aging or connective tissue disorders (marfan, ehlers danlos)
304
What is more common- ascending aortic aneurysms or descending?
Ascending (60%)
Descending (40%)
305
Descending aortic aneurysms are usually due to?
atherosclerosis
htn, hypercholesterolemia, smoking are risk factors
306
Risk factors for aortic dissection?
HTN
Marfan
Cocaine
307
Type A ascending aortic dissections can lead to aortic rupture into the?
pericardial space-> can rapidly progress to cardiac tamponade and cardiogenic shock
308
pulse differential blood pressure should make you think of?
aortic dissection
309
Diagnostic study of choice in hemodynamically stable patients without kidney injury where you suspect aortic dissection?
CT angiography
310
What test should you order for suspected aortic dissection in patients with hemodynamic instability and kidney injury?
transesophageal echo
311
Should you use B-blockers in patients with acute aortic dissection?
YES- to lower systolic blood pressure
312
Should you use anticoagulation in patients with aortic dissection?
NO
313
Three most common causes of aortic stenosis in general population?
1. senile calcific aortic stenosis
2. bicuspid aortic valve
3. rheumatic heart disease
314
Myxomatous valve degeneration causes?
mitral valve prolapse
315
regular narrow complex tachycardia =
supraventricular tachycardia
316
All patients with persistent tachyarrhythmia (narrow or wide) causing hemodynamic instability should be managed with?
immediate synchronized direct current cardioversion
317
For patients with stable, recurrent or refractory wide-complex tachy what therapy can be used?
procainamide, amiodorone
318
When is unsynchronized cardioversion (defibrillation) used?
resuscitation efforts in patients with pulseless cardiac arrest (with vfib, vtach)
319
Leriche syndrome
Aortoiliac occlusion (characterized by triad of bilateral hip, thigh, buttock claudication, impotence, symmetric atrophy of bilateral lower extremities due to chronic ischemia)
320
Pacemaker placement can cause complications to which valve?
Tricuspid valve
321
most common organism for infectious endocarditis?
staph aureus
322
Which valve is most common for endocarditis in IV drug users?
Tricuspid valve
323
numerous round alveolar infiltrates on cxray in an IV drug user with cough, chest pain, hemoptysis should make you suspicious for?
Tricuspid endocarditis -> septic pulmonary emboli
324
cardiac index =
cardiac output/body surface area
325
how do you treat viral or idiopathic pericarditis?
NSAIDs + colchicine
326
Which type of pericarditis does not typically cause diffuse ST elevation?
Uremic pericarditis
327
how to differentiate pericardial friction rub from pleuritic friction rub due to viral pleurisy?
pleural friction rub will disappear with breath holding
328
Advanced renal failure- BUN is?
BUN > 60 requires dialysis
